Table of Contents (hide)
- 1. Comparatively Effective
- 2. How Long Until Lexapro (escitalopram oxalate) Starts Working
- 3. How Effective Lexapro (escitalopram oxalate) is for its Approved Uses
- 4. Likelihood Lexapro (escitalopram oxalate) will Work for Off-Label Applications
- 5. Lexapro (escitalopram oxalate) versus Other Antidepressants for its Approved Indications
- 6. How Lexapro (escitalopram oxalate) Compares with Other Drugs for Off-Label Treatments
Two of the most important things to know when deciding on which med is the best for a particular condition1: how likely is it to work and how long will it take.
The odds of a med working for a particular condition and how long it generally takes to work should be fairly easy to nail down, and not need to be summed up by the Internet shorthand YMMV (Your Mileage May Vary). Aside from it being hard enough to get an accurate diagnosis when brain cooties are involved, why is it so difficult to figure out if Lexapro is right for you and how long it will take for you to know that?
- Because no one is quite sure exactly what causes various conditions.
- Which is further complicated when everything is a spectrum disorder (e.g. bipolar 1, bipolar 2, all the others planned for DSM-V).
- And they’re never really sure about how Lexapro works in the first place.
- Plus, if you have more than one condition for which you’re taking one or more medications to treat, things get really complicated.
- None of which is helped by studies that produce contradictory results, if they aren’t questionable in the first place.2
Always remember: if your symptoms suddenly get a lot worse, call your doctor immediately. Any drug that makes your symptoms worse is a drug you probably need to stop taking as soon as possible.
See our page on the tests researchers use to measure the efficacy of medications, including during clinical trials to get FDA approval.
Lexapro can start working within one week. As usual there are conflicting data. All the reports from people who’ve taken Lexapro that I’ve read (anecdotal evidence) indicate that Lexapro often starts working in the first week or two.
You should still give it at least three weeks, unless the side effects hit hard, fast, and don’t start getting better within two weeks of reducing the dosage (if there’s any room to reduce the dosage).
The odds are pretty good that Lexapro will work for MDD, as in you have a 60–75% chance that you’ll respond to Lexapro3 - i.e. it will do something positive - and a 60–70% chance of remission, i.e. your MDD symptoms will more-or-less go away and stay away, although you may have to keep taking your meds to ensure you stay symptom-free.
Keep in mind that:
- Serotonin reuptake inhibition, and everything else SSRIs do, is not the answer for everyone, either by itself or at all.
- When you pool all the data together (see below) you’ll find that Celexa and Lexapro are better than the other SSRIs. It’s marginally statistically significant for everyone who still takes the other SSRIs. Their real advantage comes from sucking less than the others and being better at preventing relapses, so if you and your doctor think you’re going to be depressed forever without meds, you’re way better off with Celexa or Lexapro than another SSRI or other antidepressant.
- We can’t hammer this point home as hard or often enough: antidepressants work only for people who are seriously depressed.4
Like most SSRIs the clinical trials published in the PI sheet used a ridiculously small set of people with vague results. How small? The usually don’t print the number of patients, that’s how small. Things are different in Canada, where some actual numbers are published in the PI sheet. But it tells us only that people felt somewhat better, and not how many of them did.
Unlike most antidepressants I was actually able to find the clinical trials on PubMed, although there are no more data in the abstracts than in the PI sheet. Except for Fixed-dose trial of the single isomer SSRI escitalopram in depressed outpatients. The discrepancies between the PI sheet and the abstract that are really telling. The US PI sheet, which doesn’t allow you to copy any text, has the typically vague result of “statistically significant greater mean improvement compared to placebo on the MADRS.” But when you look at the study:
Clinical response was evaluated by the Montgomery-Asberg Depression Rating Scale (MADRS), the 24-item Hamilton Rating Scale for Depression (HAM-D), the Clinical Global Impressions (CGI) scales, the Hamilton Rating Scale for Anxiety (HAM-A), and patient-rated quality-of-life scales.
RESULTS: Escitalopram, at both doses, produced significant improvement at study endpoint relative to placebo on all measures of depression; significant separation of escitalopram from placebo was observed within I[sic] week of double-blind treatment. Citalopram treatment also significantly improved depressive symptomatology compared with placebo; however, escitalopram, 10 mg/day, was at least as effective as citalopram, 40 mg/day, at endpoint. Anxiety symptoms and quality of life were also significantly improved by escitalopram compared with placebo. The incidence of discontinuations due to adverse events for the escitalopram 10 mg/day group was not different from the placebo group (4.2% vs. 2.5%; p = .50), and not different for the escitalopram 20 mg/day group and the citalopram 40 mg/day group (10.4% vs. 8.8%; p = .83).
Note how more scales are mentioned in the abstract. The PI sheet omits two points that numerous studies will repeatedly prove: while Lexapro usually doesn’t work any better than Celexa, it often does work faster than Celexa, or any other SSRI.
The Australian PI sheet confirmed that the clinical trial about preventing the relapse of depression symptoms I found before is indeed the one in the PI sheet. It, too, is pitifully small (181 taking Lexapro, 93 taking placebo), but at least it had everyone taking their pills for nine months. Close to 75% of the people taking Lexapro after 36 weeks were still not depressed, vs. 60% taking the wonder drug Placebo.
You’re probably a lot less likely to commit suicide when taking Lexapro than taking a placebo. But is that really a big surprise? I guess it is to some people.
There have been studies experimenting with dosages up to 50mg(!) a day. This is the first time I’ve read a Lundbeck-sponsored study of Lexapro where there has been a significant number of people quitting due to side effects (20%). 30mg could be a dosage to consider, especially if you know or suspect you’re a rapid or ultra-rapid metabolizer of drugs cleared by CYP2D6 (substrates), or you take a drug that induces CYP2D6, like Tegretol (carbamazepine). 40mg seems to be the upper limit of real efficacy.
Predicting if a med will work for you is something that can be really useful. What have we got for Lexapro…
- Is there a genetic test to predict if Celexa or Lexapro will work for you? Maybe. With only 40 people involved it’s too soon to tell. I’m sure the test is freaking expensive right now.
- Which is a better predictor: Omega-3 fatty acids (O3FA) or how neurotic you are? So if Woody Allen eats a lot of fish, would that mess up the study? The results: however much O3FA you have floating around won’t give you clue whether or not Lexapro may work for you, and while treating anxiety and depression at the same time is always difficult, following the usual Crazy Meds titration schedule of low dosages with no target dosage allows Lexapro to work rather well for the combination.
The story for anxiety disorders is a bit better. People in the Panic/Anxiety community love Lexapro. Like MDD efficacy rate is still around 70–75%, but as GAD (and many of the other anxiety disorders for which it’s used off-label) tends to respond at lower dosages than MDD, the side effects tend to suck a lot less than GAD and other treatments.
In regards to GAD, this double-blind study of 158 people taking Lexapro vs. 157 people taking placebo had 68% of the people taking Lexapro responding against 41% taking the placebo. Not too bad for the placebo. In Lexapro’s favor, though, on the Hamilton Rating Scale for Anxiety, those taking Lexapro averaged a 11.3 point drop from a score of 18 points or higher, whereas those taking the placebo dropped only an average of 7.4 points. So you can fool some of the people with GAD into feeling better, but even those you fool won’t feel better than they could have with a real med.
What looks like a follow up to the clinical trials for Lexapro’s approval for GAD has even better numbers than the above. Those who completed the 8-week double-blind trials were given the option of knowing they were taking Lexapro (escitalopram oxalate) 56% of the people made it to the end, so about half in all, or roughly 250 people were still helped by Lexapro (escitalopram oxalate) for generalized anxiety disorder (GAD), and helped a lot.
Just like with MDD, Lexapro helps to prevent the relapse of generalized anxiety disorder. At least when compared with placebo. After taking Lexapro for 8–12 weeks:
- In this study Only 19% of the people taking Lexapro had a relapse of symptoms compared with 56% of those who got the placebo.
- In this Lundbeck-funded study on generalized social anxiety disorder 22% of people taking Lexapro relapsed vs. 50% of those taking placebo. By their own admission Lexapro is just OK for social anxiety when compared with how it works for GAD or other meds.
- Lexapro is generally good for relapse prevention.
Except for hoarding, where you’ll want Paxil, Lexapro may as well be approved for the rest of them. Oh, wait, Lexapro is approved to treat other anxiety disorders, just not in the US. We really need a way to streamline the approval process for meds when they’re already available here and approved for something else in practically every other country on the planet. In any event…
- OCD: You can tell that Lundbeck/Forest tried for approval in the US, because I could find placebo-controlled studies with only vague results. In this Lundbeck-sponsored clinical trial-looking study they used statistical methods I’ve never seen before. And the conclusion reached by this double-blind, placebo-controlled trial was “many patients with OCD responded to the Esciatolpram at the dosage of twenty milligram per day.” C’mon guys, could you try to be more vague? Fortunately papers like An emerging role for escitalopram in the treatment of obsessive-compulsive disorder, Escitalopram in the treatment of obsessive-compulsive disorder, and Escitalopram prevents relapse of obsessive-compulsive disorder, along with all the anecdotal evidence I’ve collected, tells us that, depending on the type of OCD you have, Lexapro has a 60–70% chance of working for you.
- SAnD: It’s more of a coin-toss here, as it’s a 50–60% chance. The odds are better with Paxil and Zoloft. Here’s another early clinical trial, and they get spanked here for their vague stats.
- Panic disorders (PD), with or without agoraphobia: Unlike OCD, these aren’t all over the map. Lexapro has a good 60–70% chance of working for you regardless of the type of PD you have.
- PTSD - unfortunately there just aren’t enough data for Lexapro and Celexa for either combat or non-combat PTSD to give you any odds. SSRIs are used to treat both combat and non-combat PTSD all the time, so you may as well try it.
5. Lexapro (escitalopram oxalate) versus Other Antidepressants for its Approved Indications
- Lexapro vs. Celexa. This is one of the most asked questions we get when it comes to comparing meds, and it should be. Is there a real difference in efficacy between Lexapro and Celexa? Even though Lexapro works faster the real difference is in the long run, because Lexapro sucks a little less. So more people take Lexapro for a longer time, but the difference is such that it matters only individuals and national healthcare systems.
- Cipralex vs. Cipramil in outpatients with depression. A Lundbeck-sponsored trial. 20mg of Cipralex/Lexapro vs. 40mg of Cipramil/Celexa. The results: Lexapro worked better (76% response rate, 61% remission rate vs. 56% and 43% for Celexa), and while both didn’t suck all that much, Lexapro sucked even less (4 out of 138 quit taking Lexapro due to side effects vs. 9 out of 142 for Celexa).
- Cipralex vs. Cipramil for depression treated by primary care physicians. Another Lundbeck-sponsored trial. 10mg of Cipralex/Lexapro vs. 20mg of Cipramil/Celexa. The results: A little odd. At the end of 8 weeks Lexapro had a 63% response rate and 55% remission rate vs. Celexa’s 55% and 45%, by week 24 Lexapro had an 80% response rate and 76% remission rate vs. Celexa’s 78% and 71%. The odd part is both meds were way more effective for the moderately depressed than the severely depressed at week 8, and Lexapro was barely more effective for the moderately depressed at week 24. This runs counter to all the studies showing meds to be more effective for the severely depressed. But there are always studies with atypical results.
- Lexapro vs. Celexa vs. Effexor for efficacy and cost of treating depression. Britain’s NHS undertook this study. The results: Lexapro “dominates” Celexa and Effexor. That’s what they wrote. Lexapro “just dominates” Effexor.
- Lexapro vs. Celexa vs. Effexor for efficacy and cost of treating depression. Just like the above study, only in Spain. They also use the term “dominant.” Otherwise Lexapro had a higher remission rate than Celexa and Effexor (58% vs. 38% vs. 32%), otherwise there wasn’t much difference between Lexapro and Celexa. Both were better than Effexor.
- escitalopram vs. citalopram vs. sertraline for Unipolar Major Depression. 10–20mg of Lexapro vs. 20–40mg of Celexa vs. 50–150mg of Zoloft. The results: holy shit! 97% response rate for Zoloft vs. 90% for Lexapro vs. 86% for Celexa!?! Oh, wait, the trial was sponsored by Torrent pharmaceuticals. The real winners were the researchers. I’m taking this one with a shaker of salt.
- Lexapro vs. Celexa - which is worse to overdose on? This is actually an interesting question, as only critters have been given more than 60mg of Lexapro. Does the two-to-one dosage ratio of Celexa to Lexapro hold up when you take an entire bottle? How much difference does the r-enantiomer of Celexa make? The results: Celexa is more toxic than Lexapro, but, like all SSRIs, it’s next to impossible to kill yourself with them. Although the median dosage of Celexa was higher (310mg vs. 130mg for Lexapro. The equivalent dosage of Celexa would be 260mg.), it’s hard to tell by how much that skewed the results. The most striking was the incidence of seizures, 30 for Celexa vs. 1 for Lexapro.
- Is escitalopram really relevantly superior to citalopram in treatment of major depressive disorder? A meta-analysis of head-to-head randomized trials. This analysis of Lundbeck’s clinical trials, and some of the studies and trials listed above, calls statistical shenanigans. Their main concerns: Over-reliance on the bullshit MADRS - see the page on psych tests for more info - and disputing claims of statistical significance. I’ll leave the latter up to people with better stat chops than I have. As this is the full text and the full text is available for several of the referenced papers, you can compare them all yourself.
- Escitalopram: superior to citalopram or a chiral chimera? This analysis also calls statistical bullshit on Lundbeck’s claims that Lexapro is superior to Celexa.
- This analysis looked at the same data and thought it all looked good.
- Efficacy of escitalopram in the treatment of major depressive disorder compared with conventional selective serotonin reuptake inhibitors and venlafaxine XR: a meta-analysis. The results of this Lundbeck-sponsored cage match: Lexapro beat them all, hands down. Surprise, surprise.
- Spotlight on escitalopram in the management of major depressive disorder.
- Escitalopram versus other antidepressive agents for depression.
- Lexapro vs. nortriptyline for various aspects of depression. It’s kind of hard to tell if Lundbeck and GSK had any real influence on this study. In any event the results were: it depends on what is making you depressed. If you need to feel better about yourself, stop having to drag yourself out of bed and from one place to another, and need to know things will get better, then Lexapro is the better drug. If you need to sleep at night, eat, and want to have sex again, then nortriptyline is the better drug. Hmm, there may be something to the hypothesis floating around that men respond better to TCAs and women to SSRIs.
- Zoloft vs. Lexapro vs. Effexor vs. the brain-derived neurotrophic factor (BDNF) hypothesis of depression. A recent hypothesis of what causes depression and how meds fix it involves how much BDNF we have floating around and the effect meds have on it. The results: while all the depressed people in this study had lower amounts of BDNF than the
professional guinea pigshealthy control subjects, the meds acted very differently. Zoloft increased it after five weeks, Effexor took somewhere around six months to change it, and Lexapro didn’t affect it at all. Yet all three were about equally effective in treating depression. So much for that idea.
- Zoloft vs. Lexapro - which costs less to treat depression? The HMO bean-counters have decided that over six months it costs $919 dollars to treat someone with Lexapro and $1351 to treat them with Zoloft.
- Paxil vs. Lexapro vs. placebo for generalized anxiety disorder. Five, 10 & 20mg of Lexapro were compared with 20mg of Paxil and a placebo. The winner: 10mg a day of Lexapro. As two of the authors work for Lundbeck, who also sponsored the study and manufacture Lexapro, that’s not a particularly surprising result.
- Lexapro vs. Paxil for Social Anxiety Disorder (SAnD). This Lundbeck-sponsored study isn’t very fair, as it compares 20mg of the older, immediate-release Paxil against 5mg, 10mg, and 20mg of Lexapro. While 20mg of immediate-release Paxil is GSK’s recommendation for SAnD, it’s 25–37.5mg a day for the controlled-release flavor. While 10mg of Lexapro is equal to 10mg of Paxil, 20mg of Lexapro is more like 37.5mg of Paxil CR. So it’s not all that surprising that 20mg of Lexapro was more effective than 20mg of Paxil.
- Lexapro vs. Celexa vs. Placebo for Panic disorders. Panic disorders are off-label for Celexa as well. The results - Lexapro and Celexa are both really good for panic, and Lexapro sucks less than the placebo. This sort of thing shows up in a lot of Lexapro studies and clinical trials: “The rate of discontinuation for adverse events was 6.3% for escitalopram, 8.4% for citalopram, and 7.6% for placebo.”
- Lexapro vs. Celexa vs. Placebo for Panic disorders - the sequel. The results - Lexapro kicked Celexa’s ass, which is something you don’t see very often. This was done by DJ Stein, who is one of Lundbeck’s favorite researchers, so he could have set it up to slant things in Lexapro’s favor. The abstract isn’t very forthcoming in results: “Treatment with escitalopram was associated with significant improvement on all 5 subscales of the P&A. Citalopram was significantly different from placebo in 3 subscales. […] Escitalopram was superior to placebo on 12 of 16 items of the Q-LES-Q, while citalopram was superior on 7 items.” Unlike Dr. Stahl’s study above, there’s no hint in the abstract as to what “significant” means.
1 Assuming you were correctly diagnosed in the first place.
2 Keep in mind that according to one study, most drug studies will skew in favor of the med made by the company that sponsored the study.* That's one of my favorite "no shit Sherlock" studies, although it did help in getting conflicts of interest showing up on papers.
Two additional papers along similar lines are Why Current Publication Practices May Distort Science** and Why Most Published Research Findings Are False***. So in addition to the books we use as source material, this is why we also factor a lot of anecdotal evidence (personal experience, experiences of people we know, case reports, what people have sent us in e-mail, and what is posted all over the Internet) into our conclusions regarding the likelihood of meds working, the prevalence of various side effects, etc.
While the drug companies are getting a lot more transparent and publishing more data in the PI sheets regarding the results of the clinical trials, they still don't publish how many times a drug failed a clinical trial.****
3 The data are often contradictory when compared with Celexa. Celexa averages 60-70% for both response and remission, while Lexapro is often in the neighborhood of 70-75%; hence the big spread on the response rate that seems a bit low given the results of a lot of studies, trials, and anecdotal evidence.
4 Most of the time at any rate. There's always an outlier study or two, as you'll see if you keep reading this page.
Date created 05 Dec 2010 - 13:49 Page Creator: Jerod Last edited by: Jerod Poore on June 14, 2013, at 05:23 PM
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1 While there are plenty of books to help you with hypochondria, for some reason there’s not much in the way of websites. Then again, staying off of the Internet is a large part of curing/managing the disorder.
2 Remember kids, Microsloth operating systems are like TOS Star Trek movies with in that every other one sucks way, way more. With TOS Star Trek movies you don’t want to bother watching the odd-numbered ones. With Microsloth OS you don’t want to buy and install the even-numbered ones. Anyone who remembers ME and Vista knows what I mean.
3 Have I mentioned how open source operating systems for commercial applications is one of the dumbest ideas in the history of dumb ideas?
[begin rant] I rent a dedicated server for Crazy Meds. It’s sitting on a rack somewhere in Southern California along with a bunch of other servers that other people have rented. The hardware is identical, but no two machines have exactly the same operating systems. I don’t even need to see what is on any of the others to know this. If somebody got their server at the exact same time, with the exact same features as I did, I’m confident that there would be noticeable differences in some aspects of the operating systems. So what does this mean? For one thing it means that no two computers in the same office of a single company have the same operating system, and the techs can spend hours figuring out what the fuck the problem could be based on that alone. It also means that application software like IP board that runs the forum here has to have so many fucking user-configurable bells and whistles that even when I read the manual I can’t find every setting, or every location that every flag needs to be set in order for a feature to run the way I want it to run. And in the real world it means you can get an MBA not only with an emphasis on resource planning, but with an emphasis on using SAP - a piece of software so complex there are now college programs on how to use it. You might think, “But don’t people learn how to use Photoshop or Adobe Illustrator in college?” Sure, in order to create stuff. And in a way you’re creating stuff with SAP. But do you get a Bachelor of Fine Arts degree with an emphasis on Photoshop?
Back in the Big Iron Age the operating systems were proprietary, and every computer that took up an entire room with a raised floor and HVAC system, and had less storage and processing power than an iPhone, had the same operating system as every other one, give or take a release level. But when a company bought application software like SAP, they also got the source code, which was usually documented and written in a way to make it easy to modify the hell out of it. Why? Because accounting principles may be the same the world over, and tax laws the same across each country and state, but no two companies have the same format for their reports, invoices, purchase orders and so forth. Standards existed and were universally ignored. If something went wrong it went wrong the same way for everyone, and was easy to track down. People didn’t need to take a college course to learn how to use a piece of software.
I’m not against the open source concept entirely. Back then all the programmers read the same magazines, so we all had the same homebrew utilities. We even had a forerunner of QR Code to scan the longer source code. Software vendors and computer manufacturers sponsored conventions so we could, among other things, swap recipes for such add-ons and utilities. While those things would make our lives easier, they had nothing to do with critical functions of the operating system. Unless badly implemented they would rarely cause key application software to crash and burn. Whereas today, with open source everything, who the hell knows what could be responsible some part of a system failing. [/end rant]